Racial and Socioeconomic Equity of Tecovirimat Treatment during the 2022 Mpox Emergency, New York, New York, USA

We assessed tecovirimat treatment equity for 3,740 mpox patients in New York, New York, USA, during the 2022 mpox emergency; 32.4% received tecovirimat. Treatment rates by race/ethnicity were 38.8% (White), 31.3% (Black/African American), 31.0% (Hispanic/Latino), and 30.1% (Asian/Pacific Islander/other). Future public health emergency responses must prioritize institutional and structural racism mitigation.

values as separate categories under race/ethnicity and sexual orientation.We calculated cumulative changes in percentages of tecovirimat-treated persons in 2-week intervals according to race/ethnicity and neighborhood poverty level (defined as the percentage of residents in the patient's ZIP code living below the federal poverty level according to the American Community Survey [https://www.census.gov]).We categorized neighborhoods into 4 groups: low poverty, <10%; medium, 10%-19.9%;high, 20%-29.9%;and very high, >30%.We performed analyses by using SAS version 9.4 (SAS Institute, https://www.sas.com) and R version 4.2.3 (The R Project for Statistical Computing, https://www.r-project.org).We considered a p value <0.05 statistically significant.DOHMH's Institutional Review Board deemed this evaluation to be public health surveillance.

Conclusions
During our evaluation period, 32.4% of persons in NYC with reported mpox were treated with tecovirimat, compared with <20% nationally (10).The increasing percentages of treated persons during the outbreak was likely related to advocacy by and peer support from affected communities (11), increased prescriber familiarity with tecovirimat, and iterative revisions to the EA-IND protocol that reduced provider administrative requirements.The higher percentage of persons treated in NYC and our finding that treatment did not substantially vary by neighborhood poverty level might be attributable to the free, at-home delivery approach to tecovirimat distribution, which eliminated pharmacy access as a barrier.DOHMH also established a team to recruit and support providers to prescribe tecovirimat under the EA-IND protocol.Safety net health systems and federally qualified health centers were chosen for early outreach and technical assistance to improve access for underinsured and uninsured patients.In addition, the DOHMH team connected patients to available prescribers, if their initial providers were unable to meet EA-IND requirements.
Although percentages of tecovirimat-treated persons increased over time across all racial/ethnic groups, inequities existed.When we evaluated the cumulative percentages of treated persons in each racial/ethnic category, none approached that of White persons (≈31% for other groups vs. 38.8%for White persons) (Figure 1).Racial inequities and, specifically, lower percentages of treated Black/African American and Hispanic/Latino persons were foreseeable, because similar patterns have been observed for other medical countermeasures (e.g., mpox vaccines, COV-ID-19 antivirals, and HIV treatment) (5,12,13).Stigma from healthcare providers experienced by Black gay and bisexual men is a known barrier to sex-related healthcare access (14).Furthermore, the regulatory obligations of the EA-IND process limited the number of tecovirimat prescribers, which might have disproportionately affected Black and Hispanic/Latino communities.For example, DOHMH sexual health clinics, safety-net providers of services for Black and Hispanic/Latino men who have sex with men, did not prescribe tecovirimat until mid-September 2022 because of regulatory issues.In addition, insurance coverage inequities are a major barrier to accessing primary care (15), including mpox testing and treatment.No comprehensive data source identifies healthcare providers serving specific race/ethnicity groups, making interventions to increase equitable access to mpox countermeasures imprecise.
The first limitation of our study is that univariate analysis cannot capture all factors affecting treatment, such as differences in eligibility, healthcare access, and provider prescribing.Second, tecovirimat data were not available if the prescriber did not complete the online form when the drug was prescribed through a clinical trial beginning in mid-September 2022 or was dispensed from an inpatient pharmacy (e.g., some hospitalized patients).Lack of tecovirimat treatment data might have caused treatment undercounting, but we expect minimal effect because crossover between the trial recruitment period and our evaluation was brief, and the reporting form was mandatory for all prescribers.
In conclusion, our findings indicate racial inequity in tecovirimat treatment in NYC during the 2022 mpox emergency.Future responses to public health emergencies must prioritize institutional and structural racism mitigation from the outset to build more resilient communities and healthcare delivery systems.Additional analyses of factors (e.g., clinical characteristics, acceptability of treatment, detailed sociodemographic information) should be prioritized to assess the extent and effect of race/ethnicity on mpox treatment distribution and to inform future efforts to achieve equitable medical countermeasure access.Having comprehensive data for race/ethnicity of populations served by healthcare providers/ networks and for characteristics of persons receiving medical countermeasures is critical for improving equity in emergency preparedness and response.Although neither dataset is sufficient to overcome institutional or structural racism, the alternative, a reactive approach, will inevitably perpetuate entrenched inequities.

Figure .
Figure.Comparisons of cumulative percentages of persons with mpox treated with tecovirimat during 2-week intervals in study of racial and socioeconomic equity of tecovirimat treatment during 2022 mpox emergency, New York City, New York, USA.Percentages of mpox cases diagnosed during May 19-October 29, 2022, are indicated.Treated persons who had no prescription date (n = 22) were not counted.A) Percentages according to race/ethnicity.B) Percentages according to neighborhood poverty level, defined as: low poverty, <10% of neighborhood population; medium, 10%-19.9%;high, 20%-29.9%;and very high, >30%.

Table .
Characteristics of persons with mpox according to treatment status in study of racial and socioeconomic equity of tecovirimat treatment during 2022 mpox emergency, New York City, New York, USA, May 19, 2022-October 29, 2022* category in the  2 test.For other characteristics, people with unknown values were excluded from  2 test.§All persons who identified as Hispanic or Latino (Hispanic), regardless of race, were classified as Hispanic; all other race/ethnicity categories were non-Hispanic.¶Neighborhood poverty level was defined as the percentage of residents in a postal (ZIP) code tabulation area with household incomes of <100% of the federal poverty level according to the American Community Survey 2016-2020 (https://www.census.gov).Neighborhoods were categorized into 4 groups: low poverty, <10% of population; medium, 10%-19.9%;high, 20%-29.9%;and very high, >30%.#Unknown because of missing residential or invalid New York ZIP code.with untreated persons, a larger percentage of treated persons were lesbian, gay, bisexual, or queer (70.7% vs. 61.4%)and White (27.1% vs. 20.5%); a smaller percentage of treated persons were of unknown race/ ethnicity (8.8% vs. 11.0%) or resided in Queens (11.5% vs. 18.1%) (Table).By October 29, 2022, the percentage of treated persons was highest among those identifying as White (38.8%), then Black/African American (31.3%),Hispanic/Latino (31.0%),Asian/Pacific Islander/ other (30.1%), and unknown race/ethnicity (27.7%) (Appendix Table, https://wwwnc.cdc.gov/EID/article/29/11/23-0814-App1.pdf).Percentages of treated persons were similar (30.6%-33.9%)across neighborhood poverty levels (Appendix Table).Percentages of treated persons increased initially for all racial/ethnic groups, stabilizing by late July 2022, except for White persons, among whom percentages increased an additional month before stabilizing (Figure) *Values are no.(%)except as indicated.IQR, interquartile range; LGBQ, lesbian, gay, bisexual, and queer; NA, not applicable; ND, not done.†Gendercategories are provided as defined by the New York City Department of Health and Mental Hygiene.‡Because of a substantial number of persons who had unknown sexual orientation or race/ethnicity, those persons were included as a separate